Lincoln Haven Nursing & Rehabilitation Community
950 Barlow Road, Lincoln, MI 48742 · For profit - Limited Liability company · 39 certified beds · (989) 736-8481 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.1% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 12.0% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.1% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.0% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 6.0% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 32.9% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 2.1% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.9% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.3% | 79.5% | 79.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.53 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 38% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.4%CMS range 30.0–54.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 7.5–18.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.4–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.52 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 39 beds and averages 27.9 residents a day — about 72% occupied, or roughly 11 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.97 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.35 hrs/resident/day on weekends vs 3.79 on weekdays — 12% thinner on weekends. RN hours go from 1.09 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Fcited before2026-04-01 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide a qualified dietitian, other clinically qualified nutrition professional, and/or director of food and nutrition services who met the required qualifications in the timeframe allowed. Findings include:On 03/30/2026 at 11:15 AM the dietary manager (DM) F stated she does not have her Certified Professional Food Manager Certification and she is not a Registered Dietitian. DM F stated she has only been at this facility for a short time and has not had a chance to obtain the certifications. She stated the facility does have a Registered Dietitian (RD) for the facility.On 03/31/2026 at 09:45 AM in a phone interview with RD N, when asked if she worked full time at the facility as the Registered Dietitian, she stated she came into the facility bi-weekly, with two visits per month and also conducts remote assessments. She stated she is a consultant for the corporation. During this phone interview, the nursing home administrator NHA, entered the room and stated that RD N was full- time for this facility. When asked, the NHA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-04-01 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain general repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility. Findings Include:On 03/30/2026 at 11:05 AM observed the vegetable wash sink was indirectly connected to the floor drain, with the drain line extending down into and below the lip of the floor drain. During this observation, when asked what this sink is used for, Dietary Manager (DM) F stated that vegetables are washed in this sink.On 03/30/2026 at 12:21 PM observed the double doors for the closet in room [ROOM NUMBER] with the left closet door askew. The track that the door was to follow on top was damaged and no longer working, and the upper left portion of the left door was hanging away from the door frame about 5 inches.On 03/30/2026 at 2:17 PM observed the drain line coming from the third bin of the three-compartment sink extending down into and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's and/or their representatives were educated on the risks and benefits of prescribed psychotropic medications by obtaining informed consent prior to administration for two Residents (#7 and #21) of five residents reviewed.Findings include:Resident #7 (R7) Review of the Electronic Medical Record (EMR) revealed R7 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder and generalized anxiety. Review of the March 2026 Medication Administration Record (MAR) revealed R7 was administered the following medications per physician order: Risperdal tablet (risperidone, an antipsychotic medication used to treat schizophrenia and bipolar disorder) 0.5 milligrams (mg), one tablet by mouth daily at bedtime. Date initiated: 11/11/2025. Review of R7's Psychoactive Medication Consent Form, gleaned from the EMR and dated 11/12/2024, revealed informed consent for the medication listed as Risperdal Consta IM [injectable form of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide requisite bed hold information for three Residents (R3, R6, and R17) of four residents reviewed for hospitalizations. Findings include:Resident #3 (R3)R3 was transferred from the facility to the Emergency Department (ED) on 12/16/25. The electronic medical record (EMR) of R3 did not contain documentation pertaining to bed hold information provided to R3 and/or the resident representative of R3 as a result of the transfer to the ED on 12/16/25. R3's bed hold paperwork was blank and not filled out. Resident #6 (R6)R6 was transferred from the facility to the ED on 1/8/26, 3/19/26, and 3/27/26. The EMR of R3 did not contain documentation pertaining to bed hold information provided to R6 and/or the resident representative of R6 when R6 was transferred to the ED. R6's bed hold paperwork was blank and not filled out. Resident #17 (R17)The EMR of R17 documented transfers from the facility to the ED on 12/10/25 and 3/7/25. The EMR did not contain documentation of bed hold information provided to R17 and/or the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of assessments for one Resident (#29) of two residents reviewed for Hospice services. Findings include:Resident #29 (R29) Review of the electronic medical record (EMR) revealed R29 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, atrial fibrillation, acute respiratory failure with hypoxia and hypertension. During an interview on 3/31/2026 at 9:30 a.m., R29's Legal Guardian (LG) R reported R29 was currently receiving Hospice services at the facility. Further review of the EMR revealed a Facility Notification of Admission, form signed and dated by the Hospice provider on 10/29/2025. Resident profile information gleaned from the EMR listed R29's primary payer as the Hospice provider. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s), dated 10/31/2025 and 3/20/2026 revealed R29 was admitted to Hospice on 10/29/2025 with a current benefit period through…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed toEnsure follow-up care was documented for elevated blood glucose levels, and;Communicate with physician as ordered,for one Resident (R3) of one resident reviewed for insulin therapy. Findings include:Resident #3 (R3)According to R3's electronic medical record (EMR), R3 was admitted to the facility on [DATE] with medical diagnoses of diabetes mellitus, weakness, depression, and anxiety.Review of R3's physician order, dated 1/1/26, revealed an order for insulin lispro solution with a sliding scale of: If blood sugar is 150 to 200 give 2 units, if blood sugar is 201 to 250 give 4 units, if blood sugar is 251 to 300 give 6 units, if blood sugar is 301 to 350 give 8 units and if blood sugar is 351 to 400 give 10 units. Assess blood glucose levels three times a day prior to lunch, dinner, and bedtime. If blood glucose is greater than 400 call medical doctor.Review of R3's physician order, dated 4/17/25 until 1/1/26, revealed an order for insulin lispro…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Resident #21 (R21)Review of R21's electronic medical record (EMR), revealed an admission date to the facility on 7/3/26 with medical diagnoses of multiple sclerosis (a chronic autoimmune disease of the central nervous system where the immune system attacks the myelin sheath protecting nerve fibers, causing inflammation and scar tissue), and major depressive disorder, recurrent and in full remission.On 3/30/26 at 12:35 PM, an interview was conducted with R21 in her room. R21 was noted to have a high back wheelchair sitting next to a table and R21 was resting in her bed. R21 was asked the last time she was up in her wheelchair and replied, It has been a few days. R21 was asked why she has not been up today and replied, I can only tolerate a couple hours in that wheelchair, it is not my normal wheelchair. R21 was asked where her normal wheelchair was and replied, It was here, but now it is back home. The facility will not let me have it here. I have a power wheelchair. I was able to use it at a different facility, but this one will not allow it. R21 stated, I was not aware when I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor fluids and provide the diet as ordered for one Resident (R4) of two residents reviewed for fluid concerns.Findings include:Resident #4 (R4)The electronic medical record (EMR) revealed a most recent admission date of 8/27/2025 with diagnoses including myocardial infarction (heart attack) and chronic kidney disease. The EMR also included a physician order dated 2/5/2026 which read 1500 cc (cubic centimeters which is 1.5 liters) Fluid Restriction Diet: Regular NAS (No Added Salt) and a physician order dated 3/31/26 Lasix was increased to 40 mg daily on 3/31/26 (Lasix is a diuretic or water pill used to treat edema or fluid retention.)During an interview on 3/30/2026 at approximately 1:30 PM, R4 stated his legs swell up. He was sitting in his wheelchair with his feet resting on his bed and elevated chest high.On 3/31/2026 at 12:08 PM, R4 was observed in the dining room slurping chicken noodle soup from a bowl. Licensed Practical Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician of a change in condition related to blood glucose monitoring for one Resident (#5) of thirteen residents reviewed for a change in condition. Findings include: Resident #5 (R5): Review of R5's electronic medical record (EMR) revealed initial admission to the facility on 2/4/22 with diagnoses including Parkinson's disease, and type two diabetes mellitus. Review of R5's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Review of R5's EMR revealed the following physician's order: Insulin lispro insulin pen; 100 unit/mL (millimeter); amt (amount): Per Sliding Scale; If Blood Sugar is 200 to 250 [milligrams/deciliter, mg/dL] give 2 Units. If Blood Sugar is 251 to 300, give 4 Units. If Blood Sugar is 301 to 350, give 6 Units. If Blood Sugar is 351 to 399, give 8 Units. If Blood Sugar is greater than 400, call MD (medical doctor).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor and assess 2 Residents (#5 & #177) of 13 residents reviewed for quality of care. Findings include: Resident #5 (R5): Review of R5's electronic medical record (EMR) revealed initial admission to the facility on 2/4/22 with diagnoses including Parkinson's disease, and type two diabetes mellitus. Review of R5's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Review of R5's EMR revealed the following physician's order in part: Insulin lispro insulin pen; 100 unit/mL (millimeter); amt (amount): Per Sliding Scale; . If Blood Sugar is greater than 400, call MD (medical doctor). . Four Times A Day 05:00, 11:00, 16:00 [4:00 PM], 20:00 [8:00 PM]. Review of R5's EMR revealed the following progress note written by Licensed Practical Nurse (LPN) C on 2/14/25 at 4:51 PM: Resident with blood sugar of 518 [mg/dL]; asymptomatic. [Nurse Practitioner]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2025-02-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure interventions were implemented per physician's orders for one Resident (#16) of three residents reviewed for positioning and pressure ulcers. Findings include: Resident #16 (R16): Review of R16's electronic medical record (EMR) revealed initial admission to the facility on 7/26/22 with diagnoses including peripheral vascular disease (a disorder that causes narrowing or blocking of the blood vessels) and cellulitis of the left lower limb. Review of R16's most recent Minimum Data Set (MDS) assessment, dated 12/20/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 2/25/25 at 1:03 PM, R16 was observed lying in bed. A pair of protective boots were observed placed on a recliner across the room. When R16 was asked if she wears the boots she replied, Sometimes. R16 indicated the staff did not always put them on. R16 denied refusing to wear the protective boots. On 2/26/25 at 11:44 AM, R16 was again observed resting in bed, with the pair of protective boots…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to treat pain timely for one Resident (#177) of one resident reviewed for pain. Findings include: Resident #177 (R177) Review of R177's face sheet, dated 2/25/25, revealed admission to the facility on 2/24/25 with diagnoses including, osteomyelitis (bone infection) of the right ankle and foot, peripheral vascular disease, hypertension, and diabetes mellitus. R177 was recently admitted for rehabilitation and was post-operative from an orthopedic surgery which included amputation of his right five toes and partial foot. On 2/25/25 at 12:26 PM, R177 was observed lying in his bed with a dressing on his right foot. R177 was asked what kind of operation he had on his foot. R177 replied, I had an infection, and they had to removed part of my foot including my toes. R177 was asked about pain and stated that he was comfortable when he left the hospital and when he first got to the facility, but now he was very uncomfortable. R177 stated his current pain level was an 8-9 (pain scale 0-10). R177 further explained his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in two of two medication carts reviewed for pharmacy services. Findings include: On [DATE] at 10:30 AM, the [NAME] medication cart was observed, which was found to have three controlled substance medications that had been discontinued and remained in the medication cart as follows: a.) One blister pack from Resident #19 of tramadol 50 mg tablets that was ordered on [DATE] and discontinued on [DATE] with 9 of 15 remaining. b.) One blister pack from Resident #180 of lorazepam 0.5 mg tablets ordered on [DATE] and who was discharged from the facility on [DATE] with 15 of 15 remaining. c.) One blister pack from Resident #181 of lorazepam 1 mg tablets ordered on [DATE] and who was discharged from the facility on [DATE] with 11 of 13 remaining. On [DATE] at 1:24 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked about the destruction of controlled substances. The NHA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-05 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation relates to Intake #Mi00144666 and #MI00144651. Based on interview and record review, the facility failed to employ a qualified Certified Dietary Manager (CDM) to manage the food service department. Findings include: During the lunch meal on 6/3/24 at approximately 12:10 p.m., residents were asked about their meal. Five residents (R1, R2, R4, R6, and R7) reported concerns with minimal entrée choices, limited or no alternates being offered, decreased palatability, and some missed meals due to the limited choices and poor quality of the food at some of the meals. During an interview on 6/4/24 beginning at 12:40 p.m. Registered Dietician (RD) L confirmed the was no current CDM (Certified Dietary Manager) or DM (Dietary Manager) working in the food services department. RD L clarified a CDM or DM working on becoming certified was expected to be working in the food services department consistently and regularly and understood the concern. RD L explained they only worked four to eight hours per month and were not acting as the CDM at the facility. RD L reported the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-06-05 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation relates to Intake #MI00144651. Based on observation and interview, the facility failed to properly maintain resident equipment in safe, operating condition including two Residents (R2, R10) wheelchairs and residents' bed remote controls. This deficient practice resulted in two resident's wheelchairs being in disrepair, and the risk of injury to residents from lack of access to bed remote controls. Findings include: R2 Review of the Electronic Medical Record (EMR) revealed R2 had a recent score of 15/15 on the Brief Interview for Mental Status (BIMS) assessment, which showed R2 was cognitively intact. During an interview on 6/3/24 at 12:10 p.m., R2 was seated in a manual wheelchair at lunch, and reported staff were having problems operating their wheelchair. R2 stated, I have problems with the wheels on my wheelchair, it [the wheels] wants to go one way [to the side instead of straight]. During an observation on 6/3/24 at 12:15 p.m., R2's wheelchair was observed with worn wheels. There was no wheelchair cushion observed. R2 stated, I would like a wheelchair cushion.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-05 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation relates to Intake #Mi00144666 and #MI00144651. Based on observation, interview, and record review, the facility failed to provide four Residents (R1, R2, R4, and R7) of 12 residents reviewed for food preferences and alternate meal options, who were reviewed for food concerns. Findings include: Some identifiers have been changed to Staff, as some of the interviewees requested confidentiality. R2 Review of R2's Minimum Data Set (MDS) assessment, dated 5/01/24, revealed R2 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease and depression. The assessment revealed R2 required set up with eating and moderate assistance with transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R2 was cognitively intact. During an observation on 6/03/24 at 12:10 p.m., R2 was observed eating in the facility dining room, seated in a manual wheelchair. R2's was observed feeding herself mashed potatoes and wax beans from her plate. R2 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-05 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation relates to Intake #MI00144651. Based on observation, interview, and record review, the facility failed to act on a concern for one Resident (R8) of one resident reviewed for grievances. This deficient practice resulted in feelings of frustration for R8, and lack of timely follow-up for damaged clothing. Findings include: Review of R8's recent BIMS assessment revealed a score of 15/15, which showed R15 was cognitively intact. R8 was interviewable and fully oriented. During an interview on 6/3/24 at 2:46 p.m., R8 revealed he was the resident council president, and had a concern about his pajama pants and other items returning from the facility laundry with bleach stains. R8 explained they reported their concern to laundry staff about two weeks prior and had not received any explanation of his pants being ruined, or follow-up, and expressed feeling frustrated. During an observation on 6/3/24 at 2:50 p.m., R8's red and black checkered pajama pants were observed in his closet with his permission. The pants had three holes in them, and there were bleach stains on the lower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-02-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 25 residents. Findings include: 1. On 2/20/24 at 11:16 AM, at 11:42 AM and at 12:11 PM, Dietary Aide, staff B, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 2/20/24 at 11:44 AM, the surveyor requested the facility's hand hygiene policy from Dietary Manager, staff I, to review. At this time the surveyor asked staff I if they had conducted any training with staff on the proper procedure to wash their hands to which they stated, Yes, and we have a sign posted above our sink. On 2/20/24 at 11:23 AM, and at 11:57 AM, Cook, staff A, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 2/20/24 at 11:58 AM, the surveyor inquired with staff A if they were aware of the hand washing procedure requirements posted above the sink to which they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a secured/locked medication cart, expired medications were removed from the active medication supply room and maintain clean and sanitary medication cart for one of two medication carts and one of one medication rooms reviewed for medication storage. This deficient practice had the potential for complications related to delivery of expired medications and or medications to be lost, stolen, accidental consumed by cognitively impaired residents. Findings include: On 2/20/24 at 10:44 AM, during a tour of the facility an observation was made of the [NAME] medication cart unlocked and unattended by nursing staff. The Director of Nursing (DON) was observed sitting in her office located down an adjacent hall from the medication cart which was out of her field of vision. The DON was asked who the nurse on duty was and replied, Here she (RN D) is right now, walking down the hall. On 2/20/24 at 10:46 AM, an interview was conducted with Registered Nurse (RN) D, and when asked, indicated she had just come from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the development of new pressure ulcers and failed to provide adequate care to heal facility acquired pressure ulcers for one Resident (R27) out of two residents reviewed for pressure ulcers. This deficient practice resulted in development of additional pressure ulcers and the potential for delayed healing. Findings include: Review of R27's census, revealed admission to the facility on [DATE] with medical diagnoses including sepsis, traumatic subdural hemorrhage (bleeding inside the skull, and pressure against the brain caused by a blow to the head or fall), obstructive sleep apnea (when throat muscles relax and block the airway), hypertension (elevated blood pressure), and diabetes mellitus. R27 had a discharge on [DATE] and then a readmission back to the facility on 1/12/24. Review of R27's skin observation dated 12/4/23, revealed an area of skin impairment described on the sacrum/coccyx area as left side bruised/red and other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure bed safety by permitting physical access to the electronic bed remote (pendant) to one cognitively impaired Resident (#14) of seven residents reviewed for bed safety. This deficient practice resulted in the potential for accidents including falls and/or other injuries. Findings include: Resident #14 (R14): Review of R14's electronic medical record (EMR) revealed a most recent admission to the facility on 3/28/23 with diagnoses including Alzheimer's disease and dementia. Review of R14's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1, indicative of severe cognitive impairment. An observation made during the initial tour of the facility on 2/20/24 at 10:56 AM found R14 positioned at the highest bed height possible with a fall mat placed adjacent to the bed. The electronic bed remote control was observed within reach on R14's right side, hooked on the drawer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to meet the fluid needs for one Resident (R23) of one Resident reviewed for hydration. This deficient practice resulted in feelings of thirst and fluid seeking for a resident solely dependent on fluids via a tube. Findings include: On 2/20/24 at 11:07 AM, R23 was observed propelling his wheelchair over toward his roommate's (R10's) bedside table where 2 cups of fluid were sitting. R10 exclaimed, That guy is after my water. R10 stated his roommate (R23) often tried to drink his water and R23 was not supposed to have water to drink. R23 then moved away from the water and transferred himself onto his bed. A tube feeding apparatus was located next to R23's bed. The tube feeding was not connected and was not delivering tube feeding or fluids. During an interview at 11:15 AM, R23's family member K stated he was a frequent visitor. When Family member K was asked about R23 being hesitant to communicate verbally. Family member K stated R23 used to talk to everyone all the time, but R23 was not talking now because his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-06 · tag F0807 — failed to offer suitable drinks — patternEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure fresh water was consistently offered and provided for four residents (R3, R4, R5, and R6) of four residents reviewed. This deficient practice resulted in resident dissatisfaction and the potential for feelings of thirst and dehydration. Findings include: Observations began on 2/6/24 at 9:00 a.m. of the two hallways at the facility. When entering R3's room, it was observed that he had a large pink water pitcher at his bedside table. R3's cup was noted to be warm to the touch with less than a quarter water left inside. An interview was conducted with R3 who stated that he has not had his water filled since last night and had requested a new cup of water this morning. R3 stated he requested new water over an hour ago and was still waiting, which left him frustrated. Review of R3's 1/19/24 Brief Interview for Mental Status (BIMS) score revealed an 11/15, indicative of moderate cognitive impairment. On 2/6/24 at 9:05 a.m., R6 was observed sitting in her wheelchair with her bedside table across her lap…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ATRIUM CENTERS — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 4 of 5 | 3.7 | +0.3 vs chain |
The other 25 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ATRIUM CENTERS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2007 |
| BAILEY, ESSEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 74% | since 10/01/2007 |
| FINNEY, DONALD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 25% | since 08/22/2012 |
| ALBRIGHT ROSS, SUSAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/02/2018 |
| FERKANY, JAMES | Individual | CORPORATE OFFICER | — | since 08/01/2018 |
| ATRIUM CENTERS MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2007 |
| GUSTAFSON, PAUL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/09/2018 |
| LOCKHART, DENNIS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2018 |
CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $555K paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235543. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.